PATIENT INFORMATION
NATURAL MEDICAL CARE
Dr. Mehdi L. Khosh, ND Dr. Farhang R. Khosh, ND
Dr. Deena Beneda, ND Dr. Mehdi L. Khosh, ND
11030 Oakmont Street, Dr. Deena Beneda, ND
Suite 300 4935 Research Park Way
Overland Park, KS 66210 Lawrence, KS 66047
(913) 730-7600 (785) 749-2255
I. Patient Information
Patient Name (Last, First, Middle Initial) __________________________________________________________________
Parent or Legal Guardian (if a minor) ____________________________________________________________________
Address ___________________________________________________________________________________________
Birth date ____________________________________ Patient SS # __________________________________________
Sex: M or F Single__ Married __ Widowed __ Separated __ Divorced __
Home Phone __________________________ Work Phone ___________________ Ext. ____ Mobile _______________
When is the best time to reach you? _________________________ Email Address _______________________________
Occupation __________________________________ Employer/School ________________________________________
Employer/School Address ______________________________________________________________________________
Email Address _________________________________________
Whom may we thank for referring you? ___________________________________________________________________
II. Spousal Information
Spouse Name _______________________________________________________________________________________
Spouse Birth date ___________________________ Spouse SS # _____________________________________________
Spouse Occupation ____________________________ Spouse Employer ______________________________________
III. In Case of Emergency
Name _______________________________________________ Relationship ___________________________________
Home Phone __________________________ Work Phone _______________________ Mobile ____________________
IV. Responsible Party
Who is responsible for this account (if other than patient)? ____________________________________________________
Relationship to Patient ____________________ Responsible Party SS# ________________________________________
Responsible Party Home Phone ___________________________ Work Phone _____________________ Ext ________
I understand that I am financially responsible for all charges
___________________________________________________________________________________________________
Responsible Party Signature/Date
V. Family History
|Relation |Age |State of Health |Age at Death |Cause of Death |
|Father | | | | |
|Mother | | | | |
|Brothers | | | | |
| | | | | |
| | | | | |
|Sisters | | | | |
| | | | | |
Check if your blood relatives had any of the following:
|Check |Disease |Relationship |Check |Disease |Relationship |
| |Arthritis, Gout | | |Asthma, Hay Fever | |
| |Cancer | | |Chemical Dependency | |
| |Diabetes | | |Heart Disease, Strokes | |
| |High Blood Pressure | | |Kidney Disease | |
| |Tuberculosis | | |Other | |
VI. Medical History
What is the reason for your visit today? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Check the symptoms you currently have or have had in the past year:
GENERAL GASTRONINTESTINAL EYE, EAR, NOSE, THROAT MEN ONLY
__ Chills __ Appetite poor __ Bleeding gums __ Erection difficulties
__ Depression/Nervousness __ Bloating __ Blurred vision __ Lump in testicles
__ Dizziness/Fainting __ Bowel changes __ Crossed eyes __ Penis discharge
__ Fever __ Constipation __ Difficulty swallowing __ Sore on penis
__ Forgetfulness __ Diarrhea __ Double vision __ Other
__ Headache __ Excessive thirst __ Earache/Ear discharge
__ Loss of sleep __ Gas __ Hay fever WOMEN ONLY
__ Loss of Weight __ Hemorrhoids __ Hoarseness __ Abnormal Pap Smear
__ Numbness __ Indigestion __ Loss of Hearing __ Bleeding between
__ Sweats __ Nausea __ Nosebleeds periods
__ Rectal bleeding __ Persistent cough __ Breast Lump
MUSCLE/JOINT/BONE __ Stomach pain __ Ringing in ears __ Extreme menstrual
Pain, weakness, numbness in: __ Vomiting __ Sinus problems pain
__ Arms __ Hips __ Vomiting blood __ Vision - flashes/halos __ Hot flashes
__ Back __ Legs __ Nipple discharge
__ Feet __ Neck __ Painful Intercourse
__ Hands __ Shoulders CARDIOVASCULAR SKIN __ Vaginal discharge
__ Chest Pain __ Bruise easily __ Other
GENITO-URINARY __ High/Low Blood Pressure __ Hives Date of last period ______
__ Blood in Urine __ Irregular/Rapid heart beat __ Itching/Rash Date of last Pap ________
__ Frequent urination __ Poor circulation __ Change in moles Have you had a
__ Lack of bladder control __ Swelling of ankles __ Scar mammogram? _______
__ Painful urination __ Varicose veins __ Sore that won't heal Are you pregnant? ______
Number of children _____
Check (√) conditions you currently have and mark (X) conditions you have had in the past
__ AIDS __ Chicken Pox __ HIV Positive __ Polio
__ Appendicitis __ Diabetes __ Kidney Disease __ Prostate Problem
__ Arthritis __ Emphysema __ Liver Disease __ Rheumatic Fever
__ Asthma __ Epilepsy __ Measles __ Scarlet Fever
__ Bleeding Disorders __ Glaucoma __ Migraine Headaches __ Stroke
__ Breast Lump __ Heart Disease __ Multiple Sclerosis __ Thyroid Problems
__ Cancer __ Hepatitis __ Mumps __ Tuberculosis
__ Cataracts __ Herpes __ Pacemaker __ Ulcers
__ Chemical Dependency __ High Cholesterol __ Pneumonia __ Venereal Disease
VII. Medication and Allergies
List medications you are currently taking: ______________________________________________________________________________________________________________________________________________________________________________________________________________________
Pharmacy Name ___________________________________ Pharmacy Number _________________________________________
List allergies to medications or substances: ______________________________________________________________________________________________________________________________________________________________________________________________________________________
VIII. Health Habits
Health Habits: Check which substances you Occupational: Check if your work exposes
use and describe how much you use: you to the following:
__ Caffeine __________________ __ Stress
__ Drugs ____________________ __ Heavy Lifting
__ Tobacco __________________ __ Hazardous Substances
__ Other ____________________ __ Other ______________
IX. Signatures
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Signature ___________________________________________________________________ Date ________________________
Reviewed By ________________________________________________________________ Date ________________________
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